Oral Psoriasis - A Rare Entity.

Sir,

Psoriasis is a chronic papulosquamous disorder with rare involvement of oral mucosa and no definite clinical or histopathological criteria for oral psoriasis.

A 32-year-old male, a mason by occupation, presented with complaints of itchy scaly lesions on hands and lips for 4 years and 6 months, respectively, and pain over the small joints of the hands for 6 months. History of winter exacerbation was present with symptomatic relief on using topical steroids.

Examination revealed well-defined erythematous plaques with silvery-white scaling on the dorsum and palmar aspect of both hands. Erythematous plaques with fissuring and scaling were noted on both the lips extending onto the vermilion border. Oral cavity examination revealed fissuring of the tongue. Deformities of the fifth digit of both the hands were noted [Figures 1-3].

Figure 1

Erythematous plaques with silvery-white scales on the dorsum of hands

Figure 3

Fissured tongue

Well-defined plaques with scaling and fissuring on both lips extending onto the vermillion border

Histopathology from the lip showed psoriasiform acanthosis, parakeratosis, hypogranulosis, and suprapapillary thinning with dilated blood vessels in the superficial dermis, consistent with psoriasis [Figure 4].

Figure 4

Histopathology from lower lip (H & E stain 40×)

A final diagnosis of chronic plaque psoriasis with psoriatic arthritis and oral psoriasis was made, and the patient was initiated on methotrexate along with topical corticosteroids. The cutaneous and lip lesions showed symptomatic treatment with the above. The fissured tongue was managed conservatively.

Although the cutaneous manifestations of psoriasis are well described in the literature, there is limited data on oral involvement.[1] Psoriatic involvement of oral mucosa and other mucous membranes is seen particularly in association with specific types such as pustular psoriasis and psoriatic erythroderma. The lesions may be transient or migratory, with course of lesions parallel to remission or exacerbation of cutaneous lesions.[2]

Oral psoriasis has been reported to affect any part of the oral mucosa, including lips, tongue, buccal mucosa, gingiva, and palate.[12] Lips’ involvement in psoriasis can have varied manifestations. Typical scaly, erythematous psoriatic lesions may be seen extending from the lip and crossing the vermilion border to involve the mucosal surface as seen in our case. Exfoliative cheilitis may rarely develop concurrent with flares of cutaneous psoriasis. Angular cheilitis manifesting as erythema, scaling, and fissuring at the corners of the mouth has also been reported.[3]

The most commonly reported oral mucosal involvement is geographic tongue, seen mainly in generalized pustular psoriasis.[24] Fissured tongue as seen in our patient has been reported to be more frequent in psoriatic patients compared to the general population.[3]

Histopathology of oral psoriasis is non specific and hence clinicopathologic correlation is necessary for diagnosis.

Management of oral psoriasis aims at symptomatic improvement. The mainstay of treatment of oral psoriasis includes topical steroids and immunomodulators such as cyclosporine and tacrolimus.

Oral psoriasis is a rare entity, and there is no consensus on the description of true lesion of oral psoriasis. This case highlights a rare presentation of lip psoriasis with fissured tongue coexisting with cutaneous psoriasis. Detailed medical history and thorough evaluation help in early identification of the condition and prompt institution of treatment resulting in better clinical outcomes.

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Conflicts of interest

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